Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2012;26:3003-3039. [PMID: 23052493 DOI: 10.1007/s00464-012-2511-1]

Moving the needle for laparoscopic common bile duct exploration: defining obstacles for the path forward

INTRODUCTION

Laparoscopic cholecystectomy is performed very commonly but laparoscopic common bile duct exploration (LCBDE) is performed infrequently. We aimed to determine the most significant barriers to performing LCBDE and to identify the highest yield interventions to facilitate adoption.

METHODS AND PROCEDURES

A national survey was designed by content experts, who regularly perform LCBDE. The survey was distributed by email to the Society of American Gastrointestinal and Endoscopic Surgeons and the American Association for the Surgery of Trauma memberships. Non-U.S. surgeon responses were excluded. Descriptive statistics were used to analyze the results.

RESULTS

Seven hundred twenty six practicing surgeons responded to the survey, 543 of which were US surgeons who perform laparoscopic cholecystectomy. Only 27% of respondents preferred to manage choledocholithiasis with LCBDE. Their technique of choice was choledochoscopy (70%). Despite this, 36% of surgeons did not have access to a choledochoscope or were unsure if they did. Seventy percent of surgeons who performed LCBDE did not have supplies readily available in a central stocking location. Only 8.5% of surgeons agreed that routine LCBDE would impact their referral relationship with gastroenterology. About half the respondents (47%) considered LCBDE worth the time, but only 25% knew about reimbursement for the procedure. Almost all (85%) of surgeons understood that LCBDE results in shorter length of stay compared to ERCP.

CONCLUSIONS

Only a quarter of the surgeons performing cholecystectomy perform LCBDE. Multiple barriers contribute to low LCBDE utilization. Increasing availability of appropriate equipment, a dedicated supply cart, and teaching fluoroscopic LCBDE interventions may address limitations and increase adoption. These efforts may also increase efficiency, minimizing perceived time and skill restraints. Although many surgeons understand LCBDE decreases length of stay, they are unaware of surgeon-specific LCBDE financial benefits. Systematically addressing these barriers may increase LCBDE adoption, improve patient care, and decrease healthcare costs.

Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review

Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.

Congenital cystohepatic duct found during laparoscopic cholecystectomy

This case shows the need for in-depth knowledge also on congenital biliary anomalies that can become subject to iatrogenic damage. The patient is 44-years old with echographically proven cholelithiasis with complaints of intermittent pain in the right upper quadrant. During laparoscopic cholecystectomy, after identification of cystic duct and cystic artery, after their clipping and resection and subsequent mobilization of the gallbladder from the liver parenchyma, a bile duct was opened. Subsequent identification revealed a cystohepatic duct, which is a rare anatomic anomaly. Plastic surgery was performed on the tangential lesion of the right hepatic duct and placement of a transcistic drain, as well as a drain from the right hepatic duct through the Fateri papilla. Postoperative transdrainage cholangiography established the integrity of the bile ducts and the free passage of contrast to the duodenum. Intraoperative identification of only two structures entering the gallbladder during cholecystectomy-cystic duct and cystic artery-is mandatory.

Perioperative strategies for patients undergoing subtotal cholecystectomy: a single-center retrospective review of 102 procedures

BACKGROUND

Calculous gall bladder disease is often handled by laparoscopic cholecystectomy. In cases where a safe dissection of the hepatocystic triangle cannot be carried out, a subtotal cholecystectomy (STC) may be performed. The perioperative management of patients undergoing STC is characterized by limited evidence. This large single-center series explores some of the perioperative aspects and outcomes after STC.

MATERIALS AND METHODS

The study population includes all patients who underwent STC at Oslo University Hospital (Ullevål and Aker Hospitals) from 01.01.2014 to 30.09.2020. A STC was defined as a cholecystectomy where there was a failure to control the cystic duct during surgery. Study variables included demographic data, comorbidities, previous biliopancreatic disease, indication for surgery, perioperative information, subsequent interventions and outcome data.

RESULTS

During the study period, 2376 cholecystectomies were performed, and 102 (4.3%) were categorized as STC. Of all patients with STC, 48 (47.1%) had an intra- or postoperative ERCP during the index hospital admission. The indication for ERCP was bile leak in 37 (42.6%) of the cases. The bile leak resolution rate was 60.0 % in intraoperative ERCP vs 95.7% in postoperative ERCP. Among the STC patients, there were no injuries to the central bile ducts. Later, one patient has undergone a remnant cholecystectomy, following fenestrating STC.

CONCLUSION

STC was a safe bailout strategy for dissection in the hepatocystic triangle in difficult cholecystectomies. Intraoperative ERCP increased procedure time and was associated with a lower rate of leak resolution, as compared to postoperative ERCP.

Post Cholecystectomy Bile Duct Injury in an Acute Setting: Categorization, Triaging, and Management Algorithm

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

A systematic review on laparoscopic subtotal cholecystectomy for difficult gallbladders: a lifesaving bailout or an incomplete operation?

INTRODUCTION

Laparoscopic subtotal cholecystectomy (LSTC) is a bailout procedure that is undertaken when it is not safe to proceed with a laparoscopic total cholecystectomy owing to dense adhesions in Calot's triangle. The main aim of this review was to investigate the early (≤30 days) and late (>30 days) morbidity and mortality of LSTC.

METHODS

A literature search of the PubMed® (MEDLINE®), Google Scholar™ and Embase® databases was conducted to identify all studies on LSTC published between 1985 and December 2020. A systematic review was then performed.

RESULTS

Overall, 45 studies involving 2,166 subtotal cholecystectomy patients (51% female) were identified for inclusion in the review. The mean patient age was 55 years (standard deviation: 15 years). Just over half (53%) of the patients had an elective procedure. The conversion rate was 6.2% (n=135). The most common indication was acute cholecystitis (49%). Different techniques were used, with the majority having a closed cystic duct/gallbladder stump (71%). The most common closure technique was intracorporeal suturing (53%), followed by endoloop closure (15%). Four patients (0.18%) died within thirty days of surgery. Morbidity within 30 days included bile duct injury (0.23%), bile leak (18%) and intra-abdominal collection (4%). Reoperation was reported in 23 patients (1.2%), most commonly for unresolving intra-abdominal collections and failed endoscopic retrograde cholangiopancreatography to control bile leak. Long-term follow-up was reported in 30 studies, the median follow-up duration being 22 months. Late morbidity included incisional hernias (6%), symptomatic gallstones (4%) and common bile duct stones (2%), with 2% of cases requiring completion of cholecystectomy.

CONCLUSIONS

LSTC is an acceptable alternative in patients with a "difficult" Calot's triangle.

A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety

BACKGROUND

The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice.

METHODS

A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes.

RESULTS

Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability.

CONCLUSIONS

A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees

AIMS

The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST.

METHODS

This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction.

RESULTS

Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences.

CONCLUSIONS

These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.

Laparoscopic cholecystectomy critical view of safety (LC-CVS): a multi-national validation study of an objective, procedure-specific assessment using video-based assessment (VBA)

BACKGROUND

A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor-unsafe", "adequate-safe", or "excellent-safe".

METHODS

A multi-national consortium of 12 expert LC surgeons applied the OPSA-LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor-unsafe" vs. "adequate/excellent-safe".

RESULTS

Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00.

CONCLUSIONS

The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation.

Effectiveness of no drainage after elective day-case laparoscopic cholecystectomy, even with intraoperative gallbladder perforation: a randomized controlled trial

BACKGROUND

Laparoscopic cholecystectomy (LC) has been carried out as day-case surgery. Current guidelines do not mention the role of drainage after LC. In particular, data stay blank with no prospective study on drainage management when gallbladder perforation (GP) accidentally occurs intraoperatively.

METHODS

A randomized controlled trial was conducted to compare clinical outcomes of drainage and no drainage after elective day-case LC. Intraoperative GP was recorded. The primary and secondary outcomes were major and minor complications, respectively.

RESULTS

Two hundred patients were randomized. No major complications occurred in either group. In secondary outcomes, nausea/vomiting, pain, hospital stay, and cost were similar in the drainage group and no drainage group; postoperative fever, WBC, and CRP levels were significantly lower in the no drainage group. GP occurred in 32 patients. Male patients with higher BMI and CRP and abdominal pain within 1 month were more likely to occur GP. Subgroup analysis of GP, primary outcomes, and most secondary outcomes had no difference. Postoperative WBC and CRP were higher in the drainage group. Postoperative fever occurred in 63 patients. Univariate analysis of fever showed that blood loss, drainage, postoperative WBC, CRP, and hospital stay were significant. Multivariable logistic regression analysis demonstrated that drainage was an independent risk factor for fever after LC (OR 3.418, 95% CI 1.392-8.390; p = 0.007).

CONCLUSIONS

No drainage after elective day-case LC is safe and associated with fewer complications, even in intraoperative GP. The trial proves that drainage is an independent risk factor for postoperative fever. The use of a drain after LC may lead to an unsuccessful day-case procedure by causing fever, elevated CRP, and extended hospital stay (NCT03909360).

Secondary sclerosing cholangitis and IgG4-sclerosing cholangitis - A review of cholangiographic and ultrasound imaging

Sclerosing cholangitis (SC) represents a spectrum of chronic progressive cholestatic diseases of the intrahepatic and/or extrahepatic biliary system characterized by patchy inflammation, fibrosis, and stricturing. Primary and secondary SC must be distinguished given the different treatment modalities, risks of malignancy, and progression to portal hypertension, cirrhosis, and hepatic failure. This review focuses on secondary SC and the pathogenic mechanisms, risk factors, clinical presentation, and novel imaging modalities that help to distinguish between these conditions. We explore the detailed use of cholangiography and ultrasound imaging techniques.

Three-port laparoscopic cholecystectomy is safe and efficient in the treatment of surgical biliary disease: a retrospective cohort study

Multiple studies have suggested that three-port laparoscopic cholecystectomy is both feasible and safe. However, this approach has failed to gain acceptance outside of clinical trials, leaving adopters of this approach vulnerable to medico-legal scrutiny. We hypothesized that the three-port approach to laparoscopic cholecystectomy (LC) is safe and efficient in experienced hands. All LC (including robotic) cases were performed on patients 18 years and older between November 2018 and March 2020. Operations utilizing three ports were compared to those performed using more than three ports. The primary outcomes measured were total operative time, conversion-to-open rate, and the complication rate. A two-sample test was performed to compare operative times, and a Fisher's exact test was used to compare conversion-to-open and complication rates. Linear regression models were used to account for the effect of confounders. 924 total LCs were performed by 30 surgeons in the study period (71 three-port, 853 four or more ports). The mean operative time was 10 min shorter in the three-port group in comparison (64.1 ± 1.4 min vs. 74.4 ± 1.8 min, p < 0.01), despite a threefold higher rate of intraoperative cholangiogram in these cases (23.0% vs. 7.9%, p < 0.001). There was no significant difference in either the conversion-to-open rate (1.6% vs. 5.1%, p = 0.35), or the overall complication rate (7.1% vs. 8.7%, p = 0.82). Operative time for LC performed through three ports was significantly less than those performed through the traditional four port approach, despite utilizing intraoperative cholangiogram nearly three times as often. There was no difference in the conversion-to open rate or complication rate. These results provide considerable evidence that three-port laparoscopic cholecystectomy is comparable to four-port laparoscopic cholecystectomy in operative duration, conversion-to-open rate, and complication rate.

Percutaneous Management of Hepatic Duct Injury Using Extra-Anatomic Biliary Catheters

Iatrogenic bile duct injury during laparoscopic cholecystectomy is a known complication of low incidence. The outcome can be devastating if not recognized and managed timely and properly. In cases of iatrogenic biliary injury due to cholecystectomy, the management depends on the level of injury, the timing of discovery (intraoperative or postoperative), and the patient's condition. If discovered intraoperatively, the injury should be managed immediately. In case expertise is lacking, a surgical drain with external biliary drainage can provide a temporary alternative solution to allow for referral to a tertiary care center. If the patient is septic or not fit for surgery, a percutaneous internal-external biliary drainage (PTBD) catheter can be placed until the patient's condition improves. We report a case of complete transection of the common hepatic duct during laparoscopic cholecystectomy managed by extra-anatomic PTBD.

A retrospective analysis of bile duct injuries treated in a tertiary center: the utility of a universal classification-the ATOM classification

BACKGROUND

Bile duct injuries (BDI) are the most feared complications that can occur after laparoscopic cholecystectomy (LC). BDI have a high variability and complexity, several classifications being developed along the years in order to correctly assess and divide BDI. The EAES ATOM classification encompasses all the important details of a BDI: A (for anatomy), To (for time of), and M (for mechanism) but have not gained universal acceptance yet. Our study intents to analyze the cases of BDI treated in our institution with a focus on the clinical utility of the ATOM classification.

METHODS

We conducted a retrospective study, on a 10-year period (2011-2020), including patients diagnosed with BDI after LC, with their definitive treatment performed in our tertiary center. All injuries were retrospectively classified using the Strasberg, Hannover, and ATOM classifications.

RESULTS

We included in our study 100 patients; 15% of the BDI occurred in our center. No classification system was used in 73% of patients; 23% of the BDI were classified by the Strasberg system, 3% were classified by the Bismuth classification, 1% being classified by the ATOM classification. After retrospectively assessing all BDI, we observed that especially the Strasberg classification, as well as Hannover, over-simplifies the characteristics of the injury, many types of BDI according to ATOM being included in the same Strasberg or Hannover category. Most main bile duct injuries underwent a bilio-digestive anastomosis (60%), as a definitive treatment. An important percentage of cases (31%) underwent a primary treatment in the hospital of origin, reintervention with definitive treatment being done in our department.

CONCLUSION

The ATOM classification is the best suited for accurately describing the complexity of a BDI, serving as a template for discussing the correct management for each lesion. Efforts should be made toward increasing the use of this classification in day-to-day clinical practice.

Iatrogenic Injury of Biliary Tree-Single-Centre Experience

Cholecystolithiasis is among the most prevalent gastrointestinal disorders requiring surgical intervention, and iatrogenic damage to the bile tree is a severe complication. We aimed to present the frequency of bile duct injuries and how our facility handles these complications. We retrospectively analyzed bile duct injuries in patients undergoing surgery. We concentrated on factors such as sex, age, indications for surgery, type of surgery, primary procedure, bile tree injury, repair, and timing as well as early and late complications. There were 22 cases of bile duct injury in the studied material, primarily affecting women-15 individuals (68.2%). Eleven cases (45.7%) of acute cholecystitis were the primary reason for surgery, and an injury to the common bile duct that extended up to 2 cm from the common hepatic duct was the most common complication (European Association for Endoscopic Surgery grade 2). Roux-en-Y hepaticojejunostomy was the most common repair procedure in 14 cases (63.6%). Eleven patients (50%) experienced early complications following reconstruction surgery, whereas five patients (22.7%) experienced late complications. An annual mortality rate of 22.7% (five patients) was observed. Iatrogenic bile duct injury is a severe complication of surgical treatment for cholecystolithiasis. Reconstruction procedures are characterized by high complication rates and high mortality.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial

INTRODUCTION

Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage.

METHODS

44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand-motion analyses.

RESULTS

All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445.

CONCLUSIONS

Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis

Background

Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy.

Methods

A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI).

Results

Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93).

Conclusion

Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09267-x.

When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies

BACKGROUND

Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital.

METHODS

A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones.

RESULTS

A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P<0.0001).

CONCLUSION

Routine use of IOC resulted in low rates of BDI diagnosis, aberrant biliary anatomy identification and/or CBD stones detection. Selection of patients for IOC, rather than routine use of IOC appears a more reasonable approach.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

Long-term outcomes in the repair of intrahepatic iatrogenic bile duct lesions using a combined intraglissonian and extraglissonian approach

PURSPOSE

Iatrogenic bile duct injuries (IBDI) with intrahepatic involvement are a serious and challenging surgical complication that can have disastrous consequences in terms of morbidity and mortality.

METHODS

We collected the patients with IBDI type (E4) between January 1991 and March 2020 in our hospital. The objective of the study was to present the long-term results of a extraglissonian approach and intraglissonian biliary reconstruction in a series of patients with intrahepatic bile duct injuries after cholecystectomy. We also detail our preoperative management and the standardization of the technique.

RESULTS

An extraglissonian approach with partial hepatic resection of the base of segments 4b and 5 and intraglissonian Roux-en-Y hepaticojejunostomy for biliary reconstruction using to several branches was performed in 10 patients with E4 Strassberg type intrahepatic lesions. Only one patient had postoperative bile leak (Clavien 3a). Surgical time was 260 min (IQR, 210-490). We left transanastomotic catheter (between 2 and 5) in situ for 3 and 6 months after surgery. The patients remained asymptomatic over a median follow-up of 169 months (IQR 129-234).

CONCLUSION

This biliary reconstruction technique obtains positive long-term outcomes in patients with severe intrahepatic lesions.

Knowledge of the Culture of Safety in Cholecystectomy (COSIC) Among Surgical Residents: Do We Train Them Well For Future Practice?

BACKGROUND

Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India.

METHODS

A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS).

RESULTS

With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%).

CONCLUSIONS

Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

Thermal Processes in Bile Ducts During Laparoscopic Cholecystectomy with Monopolar Instruments. Experimental Study Using Real-Time Intraluminal and Surface Thermography

Introduction. A significant rate of complications during laparoscopic cholecystectomy (LC) occurs due to thermal injury caused by monopolar electrosurgery (MES) equipment. Most of them manifest weeks and months after surgery with the common bile duct (CBD) and large duodenal papilla strictures, some in the early postoperative period with bile leaks. Objective. To study thermal processes occurring in the lumen and on the surface of the bile ducts during monopolar coagulation in a porcine model of LC. Methods. The temperature of the bile ducts was measured using instrumentation consisted of biliary stent with temperature sensors, which was inserted in the porcine CBD, signal amplifier, and current sense transformer. Surface temperature was measured with a scientific grade thermal camera. Cholecystectomy was performed using a standard "critical view of safety" (CVS) approach with 5 mm monopolar laparoscopic instruments. Results. Application of MES caused significant tissue heating. Lateral thermal spread and the rate of tissue heating depended on the duration of energy application and the initial tissue temperature. In 5 out of 6 experiments, the intraluminal temperature rose up to the critical threshold, and the exposure time ranged from 54 to 560 seconds. A sensor positioned at the papilla site was heated in all the experiments but still below the cell damage inducing threshold. The analysis of thermographic charts revealed the presence of the "current channeling" effect and the pedicle effect. Conclusion. There is a possibility of a direct and delayed thermal injury to the bile ducts during LC.

The location of bile duct stones may affect intra- and postoperative cholecystectomy outcome: A population-based registry study

BACKGROUND

Treatment for bile duct stones (BDS) depends largely on anatomical circumstances; yet, whether the outcome of cholecystectomies is impacted by the localization of intraoperatively discovered BDS remains largely unknown.

METHODS

A population-based registry study using data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). 115,084 cholecystectomies 2006-2016 with the indications gallstone colic or complications were included. The surgical outcome between patients with distal BDS and those with at least one stone above the confluence was compared.

RESULTS

10,704 met the inclusion criteria. Patients with stones above the confluence had 16% longer operation times and significantly higher rates of intraoperative complications (OR 1.47), gut perforation (OR 4.60), and cholangitis (OR 1.96) compared to patients with distal BDS. The highest clearance rate (96%), as reflected by the need for re-ERCP, was seen after intraoperative ERCP, regardless of the localization of the BDS.

CONCLUSIONS

Stones located above the confluence are associated with increased complication risks. These findings stress the importance of carefully considering the optimal methods for BDS removal during surgery.

Investigating the effects of drainage by hemovac drain on shoulder pain after female laparoscopic surgery and comparison with deep breathing technique: a randomized clinical trial study

BACKGROUND

The incidence of shoulder pain following laparoscopic surgery has been reported to be high. This study was designed to investigate the effect of Hemovac drain on postoperative pain of women after laparoscopic surgery, dose of postoperative drug, duration of hospitalization as well as comparison with deep breathing technique.

METHODS

In this clinical trial, one hundred and fourteen female patients treated by laparoscopy were randomly assigned to three groups of 38 patients. In our study group, the Hemovac drain was implemented from the secondary trocar site with a closed system. In the deep breathing group, the patient was asked to breathe slowly and deeply three time per hour at full vigilance after surgery. In the non-drain group, laparoscopic surgery was done routinely. The severity of abdominal and shoulder pain was measured with a visual scale of pain at 3, 6, 12, and 24 h after surgery.

RESULTS

There were no significant differences in age, type of surgery, duration of hospitalization, postoperative nausea and vomiting between the groups after surgery. The severity of shoulder pain was significant between groups 3, 6, 12, and 24 h after surgery (p < 0.001). Consumption of diclofenac after operation was higher in the control group (p < 0.001). The pain level of laparoscopic surgery was not different between the three groups within the first 24 h after surgery (p = 0.841).

CONCLUSIONS

The use of Hemovac drain in female laparoscopic surgery is beneficial for reducing the subsequent shoulder pain. Further studies are recommended to investigate the effects of deep breathing as a non-pharmacological and safe method in other laparoscopic areas.

Fundus first as the standard technique for laparoscopic cholecystectomy

In previous studies the fundus first technique (FF) has been a cost-effective way to simplify the laparoscopic cholecystectomy (LC) and facilitate patient rehabilitation. The feasibility and safety profile when introducing FF as the standard technique were aimed in this study. Between 2004–2014, 29 surgeons performed 1425 LC with FF and 320 with a conventional technique. During the first year 56% were with FF and 98% during the last four years. More females, ultrasonic shears, urgent operations, daycare operations and a shorter operation time were found with FF. 63 (3.6%) complications occurred: 10 (0.6%) bleedings, 33 (1.9%) infections and 12 (0.7%) bile leakages. Leakage from cystic duct occurred in 4/112 (3.6%) when closed with ultrasonic shears and in 4/1633 (0.2%) with clips (p 0.008). A common bile duct lesion occurred in 1/1425 (0.07%) with FF and in 3/320 (0.9%) with the conventional approach (p 0.003). In a multivariate regression model, the conventional technique was a risk factor for bile duct injury with an odds ratio of 20.8 (95% CI 1.6–259.2). In conclusion FF was effectively established as the standard procedure and associated with lower rates of bile duct injuries. Clipless closure of the cystic duct increased the rate of leakage.

Early Surgical Repair of Bile Duct Injuries following Laparoscopic Cholecystectomy: The Sooner the Better

Background  We aimed to investigate the outcomes of the immediate surgical repair of bile duct injuries (BDIs) following laparoscopic cholecystectomy. Materials and Methods  Between January 2012 and May 2017, patients, who underwent immediate surgical repair (within 72 hours) for postcholecystectomy BDI, by the same surgical team expert in hepatobiliary surgery, were enrolled into the study. Data collection included demographics, type of BDI according to the Strasberg classification, time to diagnosis, surgical procedures, and outcome. Results  There were 13 patients with a mean age of 43 ± 12 years. Classification of BDIs were as follows: type E in six patients (46%), type D in three patients (23%), type C in two (15%), and types B and A in one patient each (7.6%). Mean time to diagnosis was 22 ± 15 hours. Surgical procedures included Roux-en-Y hepaticojejunostomy for all six patients with type-E injury, primary repair of common bile duct for three patients with type-D injury, and primary suturing of the fistula orifice was performed in two cases with type-C injury. Other two patients with type-B and -A injury underwent removal of clips which were placed on common bile duct during index operation and replacing of clips on cystic duct where stump bile leakage was observed probably due to dislodging of clips, respectively. Mean hospital stay was 6.6 ± 3 days. Morbidity with a rate of 30% ( n  = 4) was observed during a median follow-up period of 35 months (range: 6-56 months). Mortality was nil. Conclusion  Immediate surgical repair of postcholecystectomy BDIs in selected patients leads to promising outcome.

Routine near infra-red indocyanine green fluorescent cholangiography versus intraoperative cholangiography during laparoscopic cholecystectomy: a case-matched comparison

BACKGROUND

The aim is to evaluate safety and efficacy of near infra-red (NIR) indocyanine green (ICG) fluorescence structural imaging during laparoscopic cholecystectomy (LC) (Group A) and to compare perioperative data, including operative time, with a series of patients who underwent LC with routine traditional intraoperative cholangiography (IOC) (Group B).

METHODS

Forty-four patients with acute or chronic cholecystitis underwent NIR-ICG fluorescent cholangiography during LC. ICG was administered intravenously at different time intervals or by direct gallbladder injection during surgery. Fluorescence intensity and anatomy identification were scored according to a visual analogue scale between 1 (least accurate) and 5 (most accurate). Group B patients (n = 44) were chosen from a prospectively maintained database of patients who underwent LC with routine IOC, matched for age, sex, body mass index, and diagnosis with group A patients.

RESULTS

No adverse reactions were recorded. In group A, mean time between intravenous administration of ICG and surgery was 10.7 ± 8.2 (range 2-52) h. Administered doses ranged from 3.5 to 13.5 mg. Fluorescence was present in all cases, scoring ≥ 3 in 41 patients. Mean operative time was 86.9 ± 36.9 (30-180) min in group A and 117.9 ± 43.4 (40-220) min in group B (p = 0.0006). No conversion to open surgery nor bile duct injuries were observed in either group.

CONCLUSIONS

LC with NIR-ICG fluorescent cholangiography is safe and effective for early recognition of anatomical landmarks, reducing operative time as compared to LC with IOC, even when residents were the main operator. NIR-ICG fluorescent cholangiography was effective in patients with acute cholecystitis and in the obese. Data collection into large registries on the results of NIR-ICG fluorescent cholangiography during LC should be encouraged to establish whether this technique might set a new safety standard for LC.

Excision of a part of the bile duct as an iatrogenic injury typical for laparoscopic cholecystectomy - characteristics, treatment and long-term results, based on own material

Introduction

Cholecystectomy is associated with the risk of bile duct injury (BDI). The nature of the injury in laparoscopic cholecystectomy (LC) cases seems to be more serious.

Aim

We present an analysis of long-term results of the treatment of patients who underwent operations at our department due to iatrogenic excision of a part of the bile duct (EPBD).

Material and methods

Out of all 120 patients treated for BDI in our department we selected a group of 40 with EPBD. In all cases the corrective operation was hepaticojejunostomy. The median follow-up time was 157 (56–249) months. We evaluated risk factors for EPBD during LC compared to open cholecystectomy (OC).

Results

Among bile duct injuries referred to our centre, EPBD occurred more frequently during LC (46.7%) compared to OC (11%), p < 0.001. Injuries located in the hepatic hilum occurred more often in the case of LC (68.6%) than OC (20%), p = 0.056. We did not find a difference in the frequency of EPBD between LC and OC groups depending on the presence of acute or chronic cholecystitis. The narrow common hepatic duct was reported more frequently in the LC (68.6%) vs. OC (20%) group, p = 0.056. Satisfactory long-term reconstructive treatment results were observed in 36 (90%) of 40 patients.

Conclusions

Excision of a part of the bile duct occurs more often during LC than OC. It is often located in the hepatic hilum. Presence of a narrow common hepatic duct is a risk factor for EPBD during LC. Large diameter hepaticojejunostomy is a reconstructive procedure that promises good long-term results.

Combination of electrohydraulic lithotripsy and laparoscopy for gallbladder access in type III Mirizzi syndrome

INTRODUCTION

A 50-year-old Japanese man presented with obstructive jaundice. We performed endoscopic retrograde biliary drainage before biliary decompression. CT showed a thickened gallbladder wall with low-density areas and a 35-mm gallstone; the stone was impacted in the gallbladder neck and cystic duct. The patient was therefore diagnosed with Mirizzi syndrome (type II or III) and scheduled for laparoscopic treatment. We performed subtotal cholecystectomy and intraoperative choledochoscopy because we recognized a fistula between the gallbladder and common bile duct preoperatively.

MATERIALS AND SURGICAL TECHNIQUE

We opened the ductus choledochus, and a choledochoscope was introduced under laparoscopic guidance. An electrohydraulic lithotripsy probe with irrigation was passed through the choledochoscope to extract the gallstone.

DISCUSSION

This fragmentation technique is effective for impacted large stones observed in Mirizzi syndrome. Therefore, electrohydraulic lithotripsy with laparoscopy is effective in cases of difficult gallbladder access such as that that occurs in type II or III Mirizzi syndrome.

Efficiency of fluorescent cholangiography during laparoscopic cholecystectomy for subvesical bile ducts: A case report

•

The subvesical bile ducts are important from the potential risk for bile leakage.

•

It is difficult to identify the subvesical bile ducts intraoperatively.

•

Fluorescent cholangiography visualized the subvesical bile ducts clearly.

Introduction

The subvesical bile ducts are located in the peri-hepatic connective tissue of the gallbladder fossa. Injury of the subvesical bile ducts provokes the severe complication of bile leak. Until now, fluorescent cholangiography has been employed during hepatobiliary surgery. Herein, we report the detection of subvesical bile ducts by fluorescent cholangiography during laparoscopic cholecystectomy.

Presentation of case

A 63-year-old female was admitted to our department for surgery for symptomatic cholelithiasis. The subvesical bile ducts were not observed on drip-infusion cholangiography with computed tomography. Immediately following induction of anesthesia, 2.5 mg of indocyanine green was intravenously injected. Fluorescent cholangiography demonstrated two thin aberrant bile ducts during dissection of Calot’s triangle. We considered them to be subvesical bile ducts. We ligated them with clips, divided them, and then performed laparoscopic cholecystectomy using a standard procedure. The patient had a good post-operative recovery without bile leakage. Postoperative laboratory test results were all within normal limits. Computed tomography revealed no dilatation of the intrahepatic bile duct after laparoscopic cholecystectomy. The patient was discharged on postoperative day 4.

Discussion

Injury to the subvesical bile ducts is one of the most common causes of bile leakage associated with cholecystectomy. Fluorescent cholangiography enabled real-time identification of the thin subvesical bile ducts, which were undetectable by drip-infusion cholangiography with computed tomography.

Conclusion

Fluorescent cholangiography during laparoscopic cholecystectomy may be useful for preventing postoperative bile leakage.

Evaluation of the usefulness of the SAGES Safe Cholecystectomy Program from the viewpoint of the European surgeon

Introduction

Common bile duct injury (CBDI) is a severe complication of laparoscopic cholecystectomy (LC). To minimize its occurrence, SAGES established the Safe Cholecystectomy Program (SCP) with 6 rules to follow during surgery.

Aim

To assess the knowledge of SCP among European surgeons and their opinion on its usefulness.

Material and methods

Data were gathered using questionnaires during surgical conferences in Poland and Denmark. The questionnaire asked about the surgeon’s experience in cholecystectomy and the number of complications in the form of CBDI. It asked about the surgeon’s opinion on the usefulness of SCP rules on a 10-point scale. A comparison between specialists and residents was performed. The study has been registered in the ClinicalTrials.gov – NCT03155321.

Results

One hundred eighty-four questionnaires were gathered. One hundred fourteen (61.96%) specialists (72.8% male, mean age: 50 years) and 70 (38.04%) residents (56% male, mean age: 34 years) completed the questionnaire. Mean work experience was 22 years among specialists and 4.5 years among residents. A high percentage of specialists have experienced CBDI (46% vs. 17% of residents, p = 0.014). More specialists are familiar with the SCP than residents (49.3% vs. 21.7%, p = 0.021). Significant differences in the mean usefulness score were observed for three rules: rules 2 and 6 were found more useful by residents (mean score: 7.07 vs. 6.01, p = 0.025 and 8.70 vs. 8.27, p < 0.001), and rule 3 was found more useful by specialists (mean: 8.73 vs. 8.36, p < 0.001).

Conclusions

The awareness of the SCP in Europe is low. Participants consider the rules of the SCP to be useful during surgery, although there are differences in the usefulness scores between the groups. An educational program to promote and further implement the SCP should be established.

Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy

The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.

ATOM Classification of Bile Duct Injuries During Laparoscopic Cholecystectomy: Analysis of a Single Institution Experience

PURPOSE

Bile duct injuries (BDIs) are more frequent during laparoscopic cholecystectomy (LC). Several BDI classifications are reported, but none encompasses anatomy of damage and vascular injury (A), timing of detection (To), and mechanism of damage (M). Aim was to apply the ATOM classification to a series of patients referred for BDI management after LC.

METHODS

From 2008 to 2016, 26 patients (16 males and 10 females, median age 63 years, range 34-82 years) with BDIs were observed. Fifteen patients were managed by percutaneous transhepatic cholangiography (PTC)+endoscopic retrograde cholangiopancreatography (ERCP); five and six underwent PTC and ERCP alone, respectively. Median overall follow-up duration was 34 months. Three patients died from sepsis.

RESULTS

Out of 26 patients, 20 presented with main bile duct and six with nonmain bile duct injuries. Using the ATOM classification, every aspect of the BDI in every case was included, unlike with other classifications (Neuhaus, Lau, Strasberg, Bergman, and Hanover).

CONCLUSIONS

The all-inclusive European Association for Endoscopic Surgery (EAES) classification contains objective data and emphasizes the underlying mechanisms of damage, which is relevant for prevention. It also integrates vascular injury, necessary for ultimate management, and timing of discovery, which has diagnostic implications. The management complexity of these patients requires specialized referral centers.

Features of laparoscopic cholecystectomy in patients with chronic calculous cholecystitis and signs of ”non-functioning” gallbladder

Aim. To improve outcomes of laparoscopic cholecystectomy in patients with chronic cholecystitis and signs of “nonfunctioning” gallbladder via development of preventive, curative and diagnostic measures. Material and methods. Laparoscopic cholecystectomу was performed in 14 764 patients with chronic cholecystitis. Incidence and causes of intraoperative injury of extrahepatic bile ducts were retrospectively analyzed. Three basic forms of “non-functioning” gallbladder (hydropsy, sclerosis and atrophy, total filling by stones) were. Results. Biliary injury followed by bile leakage occurred in 38 (0.25%) cases. Intraoperative and early postoperative diagnosis was in 11 (28.9%) and 27 (71.1%) patients, respectively. Tangential trauma of common bile duct was found in 3 (7.8%) cases, complete intersection – in 8 (21%) patients. Herewith, 6 of them had sclerosis, 2 – total filling of gallbladder by stones. New diagnostic and curative approach was followed by only 2 (0.04%) cases of early postoperative bile leakage in 2010–2015. Injury of common bile duct was absent within the same period. Sclerosis and atrophy of gallbladder were diagnosed prior to surgery. Conclusion. There are 3 types of “non-functioning” gallbladder with risk of biliary trauma during laparoscopic cholecystectomy. Sclerosis and atrophy of gallbladder are predominantly followed by certain difficulties during laparoscopic cholecystectomy. New diagnostic and curative approach is useful to prevent iatrogenic biliary trauma.

Critical view of safety faster and safer technique during laparoscopic cholecystectomy?

Objective:

Incidence of Bile Duct Injuries (BDI) during Laparoscopic Cholecystectomy (LC) is reported to be higher as compared to Open Cholecystectomy. Studies have shown varying degree of success in reducing BDI by using Critical View of Safety (CVS) technique before clipping and cutting any structure. In this study, we will see whether CVS technique is faster and safer compared to conventional infundibular technique.

Methods:

This comparative study was conducted on patients who presented to Surgical Out-Patient-Department (OPD) of Khyber Teaching Hospital from July 2015 to June 2016. Total of 438 patients were divided into two groups. Group-A in which LC was done using infundibular while in Group-B, CVS technique was utilized. Two groups were compared for operating time and BDI.

Results:

The operative time was significantly reduced for LC using CVS technique (50 mins vs. 73 mins). Minor leaks were comparable (0.5% vs. 0.9%) but there was a significant difference in major LEAKS between the two techniques (0.5% vs. 1.4%).

Conclusion:

Although the “critical view of safety” requires more dissection as compared to infundibular technique, but once learnt and mastered, it is faster and safer identification technique during laparoscopic cholecystectomy.

Retroperitoneal bile leak after laparoscopic cholecystectomy

Bile duct injury (BDI) is a well-recognised complication of laparoscopic cholecystectomy (LC). Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. This manifests as non-specific abdominal pain and fever occurring several days after the surgery. It can be managed by laparoscopic washout with or without bile duct repair. We present a rare case of retroperitoneal bile leak post-LC. The mechanism of injury here was likely partial avulsion from excessive traction of the cystic duct during intraoperative cholangiogram. Diagnosing retroperitoneal bile leak can be difficult because it is extremely rare and the presenting symptoms can be similar to an intraperitoneal bile leak. A high index of clinical suspicion is required. In cases of suspected bile leak, any mismatch between the exploratory laparoscopic findings and imaging findings should alert surgeons to consider the rare possibility of a retroperitoneal bile leak.

Liver Transplantation for the Treatment of Complicated Iatrogenic Biliary Injuries: A National Review from the UNOS Data Set

BACKGROUND

Liver transplantation (LT) is rarely indicated in the management of iatrogenic bile duct injuries (IBDI), but occasionally, it becomes the only remaining therapy. The purpose of this study is to evaluate potential complications of IBDI and their impact on perioperative mortality, graft, and patient survival after LT.

METHODS

The United Network for Organ Sharing database was queried for all LT performed in the United States between 1994 and 2014. Of the 101 238 liver transplants performed, 61 were related to IBDI. We performed a case matched analysis in a 5:1 ratio.

RESULTS

The median age for patients with IBDI was 50.16 ± 11.7 years with a mean Model End-Stage Liver Disease score of 22.6 ± 9.8. Patients receiving LT for IBDI were more likely women (54.1%, P = 0.001), had lower incidence of hepatitis C virus infection (4.9%, P = 0.001) and longer cold ischemic time (P = 0.001). The mean body mass index was 25.5 ± 5.2 in patients transplanted for IBDI. IBDI was recognized as the strongest independent predictor associated with eightfold increased risk of early graft loss (P = 0.001; odds ratio, 8.4) and a 2.9-fold increased risk of 30-day mortality after LT in a case matched analysis (P = 0.03).

CONCLUSIONS

IBDI is an uncommon but challenging indication for LT. These patients have significantly increased rates of early graft loss. IBDI is an independent factor related to increased risk of perioperative death after LT. Further studies are needed to determine the causes of perioperative complications and identify potential modifiable factors to improve outcomes in patients undergoing transplantation for IBDI.

Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease

BACKGROUND

Recent data have suggested that upfront cholecystectomy should be performed even in the presence of moderately abnormal liver function tests (LFTs). As a consequence, more common bile duct (CBD) stones are discovered on intra-operative cholangiogram. We assessed the presentation and management of such patients to refine their management plan.

METHODS

Adult patients (>16 years) with an acute gallstone-related disease who had undergone same-stay cholecystectomy from January 2013 to January 2015 were retrospectively assessed. We excluded patients with pre-operative endoscopic CBD exploration.

RESULTS

Among the 612 patients with same-stay cholecystectomy, 399 patients were included in the study, and 213 were excluded because of a pre-operative CBD exploration. Fifty patients (12.5%) presented an image of CBD stone on the intra-operative cholangiogram. Such patients were younger (47 vs. 55 years, P = .01) and less likely to present with fever (1 vs. 11.7%, P = .04) or signs of cholecystitis on ultrasound (66 vs. 83.7%, P = .003). Admission LFTs were higher in patients with an image of a stone. Among the 50 patients with an image on cholangiogram, a stone was confirmed in 26 (52%). Most patients (n = 32) underwent post-operative assessment with endoscopic ultrasound (EUS). LFTs did not predict the presence of a confirmed stone. However, the absence of contrast passage into the duodenum was negatively associated with a confirmed stone (P = .08), and a filling defect was positively associated with one (P = .11). Most confirmed stones were successfully extracted by endoscopic retrograde cholangiopancreatogram (ERCP) (25/26, 96%), except in one patient who needed a per-cutaneous approach because of duodenal diverticuli.

CONCLUSIONS

Same-stay cholecystectomy can (and should) be performed even in the presence of moderately abnormal liver function tests. The cholangiogram suspicion of a CBD stone is confirmed in only half of the patients (more often in the presence of a filling defect, and less often with the absence of contrast passage). All stones can be safely treated after surgery (most by ERCP).

Assessment of available evidence in the management of gallbladder and bile duct stones: a systematic review of international guidelines

BACKGROUND

Gallstone disease is a frequent disorder in the Western world with a prevalence of 10-20%. Recommendations for the assessment and management of gallstones vary internationally. The aim of this systematic review was to assess quality of guideline recommendations for treatment of gallstones.

METHODS

PubMed, EMBASE and websites of relevant associations were systematically searched. Guidelines without a critical appraisal of literature were excluded. Quality of guidelines was determined using the AGREE II instrument. Recommendations without consensus or with low level of evidence were considered to define problem areas and clinical research gaps.

RESULTS

Fourteen guidelines were included. Overall quality of guidelines was low, with a mean score of 57/100 (standard deviation 19). Five of 14 guidelines were considered suitable for use in clinical practice without modifications. Ten recommendations from all included guidelines were based on low level of evidence and subject to controversy. These included major topics, such as definition of symptomatic gallstones, indications for cholecystectomy and intraoperative cholangiography.

CONCLUSION

Only five guidelines on gallstones are evidence-based and of a high quality, but even in these controversy exists on important topics. High quality evidence is needed in specific areas before an international guideline can be developed and endorsed worldwide.

Importance of critical view of safety in laparoscopic cholecystectomy: a survey of 120 serial patients, with no incidence of complications

Backgrounds/Aims

To determine the importance of critical view of safety techniques in laparoscopic cholecystectomy.

Methods

A total of 120 patients were included in the study, between January 2015 to March 2016. Hydrodissection was performed for cases presenting with severe adhesions or cholecystitis. A critical view of safety was performed for all patients undergoing the procedure for isolation of cystic duct and cystic artery with cystic plate dissection. Demographic characteristics of the patients, as well as intraoperative and postoperative minor or major complications were recorded.

Results

A total of 81 (67.5%) female and 39 (32.5%) male patients succesfully underwent surgeries following the critical view of safety and hydrodissection technique. Acute/chronic cholecystitis, or severe adhesions in the surgical field, were detected in 34 (28.3%) patients. There were no intraoperative or postoperative biliary complications. Wound infection was detected in 5 (4.1%) patients. All patients were discharged on either the first, second or third postoperative day.

Conclusions

Biliary duct injury during laparoscopic cholecystectomy is an important complication. In this study, we show that the critical view of safety and hydrodissection techniquesminimizes the bile duct injury during laparoscopic cholecystectomy, including in difficult cases.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

The difficult gall bladder: Outcomes following laparoscopic cholecystectomy and the need for open conversion

INTRODUCTION

Surgery for the difficult gallbladder (DGB) is associated with increased risk compared to more routine laparoscopic cholecystectomies (LC). Laparoscopic "damage control" methods including cholecystostomy, fundus-down approach and subtotal cholecystectomy (SC) have been proposed to avoid conversion to open. We hypothesized that a Total LC (TLC) for DBG can be completed safely with an acceptably low conversion rate.

MATERIAL AND METHODS

All patients that underwent LC from January 2005-June 2015 were retrospectively reviewed. Cases met criteria for DGB if they were necrotic/gangrenous, involved Mirizzi syndrome, had extensive adhesions, were converted to open, lasted more than 120 min, had prior tube cholecystostomy or known GB perforation.

RESULTS

A total of 2212 patients underwent LC during the study time period, of which 351 (15.8%) met criteria for DGB. Of these cases, 213 (60.7%) were admitted from the emergency department and 67 (19.1%) underwent urgent/emergent cholecystectomy (within 24 h). Additionally 18 (5.1%) had pre-operative tube cholecystostomies. Seventy patients (19.9%) were converted to open. Indications for conversion included severe inflammation/adhesion (n = 31, 46.3%), difficult anatomy (n = 14, 20.9%) and bleeding (n = 6, 9.0%). Predictors for conversion included urgent/emergent intervention (OR, 0.80; 95% CI 0.351-0.881, p = 0.032), previous abdominal surgery (OR, 2.18; 95% CI, 1.181-4.035, p = 0.013) and necrotic/gangrenous cholecystitis (OR, 1.92; 95% CI, 1.356-4.044, p = 0.033). Comparing the TLC and the conversion groups, mean operative time and length of hospital stay were significantly different; 147 ± 47 min vs 185 ± 71 min; p < 0.005 and 3 ± 2 days vs 5 ± 3 days; p = 0.011, respectively. There was no significant difference in postoperative hemorrhage, subhepatic collection, cystic duct leak, wound infection, reoperation and 30 day mortality. There was no bile duct injury in either group.

CONCLUSION

Total laparoscopic cholecystectomy can be safely performed in difficult gallbladder situations with a lower conversion rate than previously reported. Possible predictors of conversion include urgency, necrotic gallbladder and history of prior abdominal surgeries. For patients converted to open, similar morbidity and mortality can be expected.

Cost-effectiveness of a new strategy to identify uncomplicated gallstone disease patients that will benefit from a cholecystectomy

Background

The aim of this study was to determine the cost-effectiveness of a new strategy for the preoperative detection of patients that will likely benefit from a cholecystectomy, using simple criteria that can be applied by surgeons. Criteria for a cholecystectomy indication are: (1) having episodic pain; (2) onset of pain 1 year or less before the outpatient clinic visit.

Methods

The cost-effectiveness of the new strategy was evaluated against current practice using a decision analytic model. The incremental cost-effectiveness of applying criteria for a cholecystectomy for a patient with abdominal pain and gallstones was compared to applying no criteria. The incremental cost-effectiveness ratio (ICER) was expressed as extra costs to be invested to gain one more patient with absence of pain. Scenarios were analyzed to assess the influence of applying different criteria.

Results

The new strategy of applying one out of two criteria resulted in a 4 % higher mean proportion of patients with absence of pain compared to current practice with similar costs. The 95 % upper limit of the ICER was €4114 ($4633) per extra patient with relief of upper abdominal pain. Application of two out of two criteria resulted in a 3 % lower mean proportion of patients with absence of pain with lower costs.

Conclusion

The new strategy of using one out of two strict selection criteria may be an effective but also a cost-effective method to reduce the proportion of patients with pain after cholecystectomy.

Temporary Trans-jejunal Hepatic Duct Stenting in Roux-en-y Hepaticojejunostomy for Reconstruction of Iatrogenic Bile Duct Injuries

BACKGROUND

Bile Duct Injuries (BDI) during cholecystectomy are now being recognized as major health problems.

OBJECTIVES

Herein, we present our experience with handling major BDIs and report long-term outcome of hepaticojejunostomies followed by trans-jejunal hepatic duct stenting performed to reconstruct extra-hepatic biliary tracts.

MATERIALS AND METHODS

In this case series, we prospectively collected data of 22 patients, who underwent first time biliary reconstruction through Roux-en-y hepaticojejunostomy followed by hepatic duct stenting using a trans-jejunal bifurcated 6F tube drain. The long-term outcome was assessed and defined as excellent (asymptomatic, normal liver enzymes and bilirubin levels), good (asymptomatic, mild abnormality in liver enzyme and bilirubin levels), poor (symptomatic, abnormal liver enzymes and bilirubin level) and failure (requiring reoperation).

RESULTS

A total of 22 patients including four males (18.1%) and 18 females (81.8%) were evaluated. The mean age was 42.71 (range: 23 - 74) years. Twelve patients had undergone open cholecystectomy (54.5%) and the rest had a history of laparoscopic cholecystectomy. The mean interval between the primary operation and reconstruction was 92.71 days. The mean follow-up period after biliary reconstruction was 42.33 (range: 1 - 96) months. No instance of anastomotic leakage or stenosis, biliary sepsis, thromboembolic event, or respiratory infection was noted in the long-term follow-up. The outcome was excellent in all patients. No case with poor or failure of result was noticed.

CONCLUSIONS

Although a devastating complication iatrogenic major bile duct injuries can be corrected surgically with a high rate of success. Temporary trans-jejunal stenting of the hepatic ducts can help in maintaining the integrity of anastomosis without stenosis or biliary sepsis.